What is the treatment for a female patient with a history of prolonged tampon (intrauterine device) use for several days without symptoms of toxic shock syndrome (TSS)?

Management of Retained Tampon Without Toxic Shock Syndrome Symptoms

Remove the tampon immediately and perform a thorough pelvic examination to ensure complete removal of all foreign material. 1

Immediate Management

Tampon Removal and Assessment

• Remove the retained tampon as soon as possible, even in the absence of toxic shock syndrome (TSS) symptoms 1
• Perform a complete pelvic examination to confirm no retained fragments remain in the vaginal vault 1
• Inspect the vaginal mucosa for signs of erosion, ulceration, or inflammation 1

Clinical Evaluation for Subclinical TSS

While the patient is currently asymptomatic, assess for early or subtle signs of TSS:

• Check vital signs including temperature, blood pressure, and heart rate for early hypotension or fever 2, 3
• Examine skin for any erythematous rash, particularly on palms and soles 4, 5
• Assess for gastrointestinal symptoms (nausea, vomiting, diarrhea) which may be early manifestations 2, 3
• Evaluate mental status and level of consciousness 1

The absence of symptoms does not eliminate risk, as TSS can progress rapidly from normal vital signs to shock within hours. 2

Culture and Laboratory Considerations

Vaginal Cultures

• Obtain vaginal cultures for Staphylococcus aureus and Group A Streptococcus before any antibiotic administration 2, 6
• These cultures help identify the causative organism if symptoms develop later 2, 5

When to Consider Laboratory Testing

If any concerning signs are present (even mild):

• Complete blood count, comprehensive metabolic panel, and coagulation studies 1
• Blood cultures if fever or systemic symptoms develop 1

Antibiotic Therapy Decision

For Asymptomatic Patients

Prophylactic antibiotics are NOT routinely indicated for asymptomatic patients with retained tampons. 1

However, consider empiric antibiotic coverage if:

• The tampon was retained for >7-10 days 4
• There is visible vaginal mucosal injury or ulceration 1
• The patient has risk factors for severe infection (immunocompromised, diabetes) 1

If Antibiotics Are Initiated

Use anti-staphylococcal coverage that includes anti-toxin activity:

• Clindamycin 600-900 mg IV/PO every 8 hours (inhibits toxin production) 1
• Plus beta-lactamase resistant anti-staphylococcal agent (e.g., nafcillin, vancomycin if MRSA risk) 1

Patient Education and Follow-Up

Immediate Instructions

• Advise the patient to avoid tampon use indefinitely or at minimum until complete mucosal healing is confirmed 4
• Provide clear warning signs of TSS to monitor: fever >102°F, rash, hypotension, confusion, vomiting, diarrhea 4, 5
• Instruct immediate return to emergency department if any symptoms develop within 48-72 hours 2, 3

Follow-Up Care

• Schedule follow-up examination in 48-72 hours to reassess vaginal mucosa 1
• Consider repeat examination in 1-2 weeks if mucosal injury was present 1
• Counsel on alternative menstrual hygiene products (pads, menstrual cups with proper hygiene) 4

Critical Pitfalls to Avoid

Do not dismiss the patient without proper examination and removal confirmation. Even asymptomatic patients can develop fulminant TSS within hours of presentation. 2

Do not assume complete removal without direct visualization. Tampon fragments can remain and continue to serve as a nidus for bacterial toxin production. 1, 3

Do not delay removal to obtain cultures first. Remove the foreign body immediately, then obtain cultures from the vaginal vault. 1